The Fixed Podcast

Shaping the Debate: Opinions in Full Arch Implant Dentistry with Dr. Damon vs Dr. Stanley: Part 2

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Does successful implant dentistry depend more on the tools you use or the brain behind them? This riveting debate between two masters of full arch implant restoration showcases fundamentally different approaches to achieving predictable success.

Dr. Damon champions freehand surgery with unwavering confidence, arguing that true mastery comes from maintaining complete anatomical awareness and adaptability. "Your brain is the guide," he asserts, explaining how this approach allows surgeons to pivot instantly when encountering unexpected challenges during surgery. His patients thank him for removing the burden of guided surgery, appreciating both the clinical flexibility and reduced costs.

Meanwhile, Dr. Stanley applies engineering optimization principles to implant dentistry, challenging conventional wisdom about stability, torque, and surgical planning. "The idea of undersizing an osteotomy meaning that you made the hole smaller means that when you put the thread in, it's going to compress the bone more," he explains, unveiling how guided surgery creates predictable stability even in challenging bone quality. His revolutionary perspective on torque—demonstrating how a zero-torque implant can have 100% stability—forces listeners to question fundamental assumptions about implant success.

Both doctors present compelling evidence for their methods, sharing illuminating clinical examples and practice management insights. Whether discussing pterygoid implants, stackable guides, or the globalization of digital dentistry, this conversation transcends mere technique to explore the philosophy behind predictable outcomes. For practitioners weighing efficiency against flexibility, or considering the true definition of implant stability, this episode delivers paradigm-shifting perspectives.

What's your approach to full arch implants? Have you found your perfect balance between planning and adaptability? Share your experiences and continue the conversation!

Dr. Tyler Tolbert:

My name is Dr Tyler Tolbert and I'm Dr Soren Papi, and you're listening to the Fix Podcast, your source for all things implant dentistry.

Dr. Tyler Tolbert:

Yeah, so that, actually, I think that transitions us pretty well into my next topic. So we talk about the dangers that come along with placing pterygoid implants that's what you mentioned, dr Damon. So we can get disoriented right, and even when we're doing freehand surgery and we've done it a million times it's very possible to get your eyes tired, maybe you're a little bit off angle, maybe you thought you were, you had everything locked in, but you got deviated, or you just got a whole lot deeper than you expected to, and so one thing that a lot of doctors are proponents of is guided surgery even guided pterygoids as well and so one thing I did want to talk about is the role of guided surgery specific to full arch. So it's one of the most hotly debated and polarizing topics in all of full arch dentistry is should we be doing this guided or should we be doing this free-handed? So advocates of guided surgery are going to be touting the predictability that comes from it, the precision, being able to get implants in the correct location and being able to reduce the risk of complications that can arise from the sort of human error that you just mentioned about your data.

Dr. Tyler Tolbert:

So, conversely, though, advocates for freehand surgery would argue that working without guides allows for a lot more flexibility and the ability to react to complications, anatomical variations. We have all seen where you've got a CBCT ahead of time. You thought you knew what you were getting into, and then you open it up and something was totally different, right? So, dr Stanley, you were a huge advocate for guided surgery and in your video I placed guided implants in even the toughest cases. You stated that guided surgery can be done anywhere in the mouth on any patient and that implants placed guided are more predictable, have decreased rates of infection and will undergo less mechanical stresses. Conversely, as for Dr Damon, you have stated in the past that freehand surgery, completed with proper training, allows for the most flexibility in trophic cases and the ability to pivot to the use of zygomatics or other remote anchorage techniques when things don't go as planned. So, dr Damon, I'll have you expound on this one first, from the freehand side of things.

Dr. Clark Damon:

Sure. So you know all of my cases are guided and you know they're brain and anatomy guided and that allows an open mindset. I can react to whatever type of situation occurs. And we've all seen it, we've all had it, we have evaluated a CBCT beforehand and we've, you know. Let's just say it's a simple infection. I have watched these apical infections grow to much larger than what the CBCT shows and I mean I have taken infections out that have traveled. You know three teeth. You know anterior or posterior to that you know.

Dr. Clark Damon:

We can all say that we reduce and or sorry, that we extract teeth atrophically. But on occasion you can, you can definitely. You know, fracture a buckle plate and you have to be able to pivot, so I, I, I advocate for free hand in all cases. Some of my most stressful cases were the ones that I did guided and you know, maybe I didn't set up the cases how Dr Stanley may.

Dr. Clark Damon:

However, you know this was using, you know, the Nobel Guide. This is back in 2014, 15. And you know really long drills because I always want to maximize my AP spread. And so how can I maximize my AP spread if I can't even get the drill back there for your posterior angle?

Dr. Clark Damon:

In addition, whenever, whenever you do a guided case or at least my experience and what I hear from other individuals is that you leave your brain in your office and your brain did not come to the surgery room because you have given it up. The second you've walked in the door, you've said the guide is going to be my guide and I'm going to do everything that this guide tells me to do. So we don't have an open mind when going in to do everything that this guide tells me to do. Uh, so we don't have an open mind when, uh, going in to do guided cases. Um, and you know, I, I, I would challenge you guys have seen my cases. I think if you look at my x-rays, my x-rays will look better free-handed than they would look guided, even with the Yomi. I look at other Yomi doctors, I look at their x-rays and I'm just like, okay, there's lack of symmetry, these implants aren't at the same depth and I have not been impressed with looking at Yomi x-rays.

Dr. Clark Damon:

You know, I know that's dynamic guided, but so my position is open mind, free hand and I think it's in my hands is safer and more predictable. And I'll tell you this, the guys that come, and guys and gals that come take my courses, they seem like they have a weight taken off their shoulders. When I tell them that they can do the cases freehand, they are like oh my gosh, dr Damon, thank you, you know, and I I think it saves them money. You know, I don't know, I don't know, I don't know what current guide prices are. You know, but I mean, I remember the days where guides were several thousand dollars apiece and I'm a huge proponent of just save money and give it to your kids, you know. So so to me, things that we, we can do, that lower cost is a win for everybody. So those are my thoughts.

Dr. Tyler Tolbert:

All right, Dr Stanley.

Dr. Robert Stanley :

So you know, I often hear the statement I want to be able to adjust during surgery, I want to be able to pivot or whatever the term you want to use. And I'm always shocked when people say that and because when I approach a surgery, I approach it a little bit different. Let me explain. In engineering, we do something called an optimization problem. So if we're going to design something, let's say we're going to design something, okay, we don't want to make it bigger than it needs to be, but we don't want to make it too small, we want to make it just right, okay. So if you make a screw too big, it costs more and it carries too much weight. So if you're trying to launch something into space, you don't want big screws, right. But if your screw's not big enough, then your spaceship falls apart. So there's somewhere in the middle where the screw is the exact best size for that solution. In engineering we do it all the time. We typically do it through mathematics. Okay, we say through math, we say what's the optimal solution? When it comes to dental implants, I optimize my implant location prior to the surgery. So we do a virtual surgery. So we're going to do the surgery on the computer before we ever do the real surgery right. And what do I mean by that? Well, we're going to virtually place implants. Those implants are going to be optimally placed, they're going to be the optimal length. So, as we were talking earlier, we want to stay. What was it? 18 millimeters is the ideal range for the pterygoids, not 25. So there's a reason for that right. So when you're designing your case, you're saying what is the optimal length, what is the optimal diameter of my implant? Where would be the absolute perfect location for the multi-unit to stick out of the gums so that it would be in the perfect location for my screw access hole, for my zirconia prostheses? You see what I'm talking about. So we're going to start with the teeth, then we're going to back into where the exact perfect implants are the number of implants, the size of the implants, the locations and all of that. And now we have the perfect plan. There is no deviation from that plan that is going to do anything for you, but make the system worse.

Dr. Robert Stanley :

So when you go in so this is, this is a concept if you've been practicing for a while people will say well, the the concept of the rescue implant. You guys recall the term the rescue implant. So this guys recall the term the rescue implant. So this comes from the old days when, when the when the metric for success was did the implant stick in the bone? So we used to say we did a surgery and we walk out of the surgery and go the implants in the bone, that was success, right, that's how we used to measure success, really literally. And so the way that worked is that I tried to put an implant in and I got a spinner.

Dr. Robert Stanley :

So you turn to your assistant and go get the next bigger implant, and so you put a bigger implant in the hole and you and you get. You get primary stability and you and you're done. Okay, okay, great. But but the problem with that concept is is that if you could have placed the bigger implant, you you would have start with, started with that in the first place. Okay, the reason you didn't start with that in the first place, okay, the reason you didn't start with it in the first place, is because, theoretically, the implant you pushed in that spot in the first place was the optimal implant.

Dr. Robert Stanley :

So if you could only get a 4.2 millimeter implant and a premolar and you say, well, okay, I don't have stability, so get me a bigger implant. So you say, well, give me a 5.2. Now, right, what happens? You blow out the buccal bone. Now you get stability, you get it to integrate and then you get a dehiscence and the facial, and then you don't get integration long-term, you get temporary integration and then you get a soft tissue dehiscence and then you're calling up your periodontist friend and saying I need a connective tissue graft and a bone graft or whatever to try to solve this problem. Which the problem was? The implant was the wrong size In this case. If it was the wrong size, just by going to a bigger implant, well, it's the same thing with these surgeries.

Dr. Robert Stanley :

At what point in my surgery would I want to pivot? It's shocking to me to think that while I've got someone under sedation, that I would change my plan. You see, my plan was optimized in the comfort of my office, drinking a cup of coffee with no one bothering me, where I was focusing on that patient and optimizing the solution for them, such that when I go to the surgery there is no pivot. So the concept of I'm going to leave my brain in the other room, that makes a lot of sense, because when you go in, at the time that you go in, it's time to execute. It's time to execute the said plan. It's time to execute the said plan. It's not time to change the plant, it's time to execute the same plan.

Dr. Robert Stanley :

And I don't know when people say, well, there could be things could change. I, I, the landscape's not going to change. You're going to. You're the the the volume of bone is not going to change. All of your planning is not going to change. Even if you have more infection than you thought, your plan doesn't change. You just had more infection than you thought. But if you're using good standard practices for primary stability, you're going to be able to predict your primary stability and you're going to have a success. You're going to have a win. So that's kind of how I look at it and I look at the surgical guide as a tool. So some people get really upset about this.

Dr. Robert Stanley :

As you started with the introduction here, you said this is a hot topic, right, so you got. People are like, hey, no, freehand is the way to go and that kind of thing religious about this. All I'm saying is it's a tool. And if you have a tool that can help you accomplish your goal, which is laid out, then why not use it? I like to make the analogy uh, you're building a house and while you're building a house, your hammer breaks. Okay, it's 11 am, your hammer breaks. You have a choice you can pick up a stone and you can keep driving nails with a stone, or you could go to home depot and get a new hammer, okay. And I think most of us would say, okay, hey, joe, hold on, I gotta go get a new hammer. We pause for a minute, we go get a new hammer, right? So that's the concept of hey, uh, you know, uh, if it breaks, I gotta go back to freehand. You know, if I, if my, if my guy doesn't break, if it doesn't work, I gotta go back to freehand. Well, that's never happened in my career. Now I've had plastic break and it predicted, you know, most of the prac.

Dr. Robert Stanley :

Uh, the guides that are broken were were early on in the practice, like early on in the years, back when the guides used to cost a lot and those plastics were weak. So, you know, you can print. You can print the guide in your office now in minutes, with a, with a Sprintrate printer, and your print cost is about $2. And then you put a master cylinder in there, and the master cylinder is about $12 to $15, depending on the company you're using. So you're looking at a total hard cost for you as a surgeon of around $15. And then you've got to pay, of course, your overhead for your labor and such. But the old days of guides costing $500, $600 and such, those days are gone. Now, for full mouth cases, the guides are still a little more expensive because typically you're using a company to help you plan those cases, and so then you get on a go-to meeting, you review the case with them and you verify that the positions meet your design, your surgical goals and your prosthetic goals. So those can cost a little bit more, but the benefits are.

Dr. Robert Stanley :

Is that I did a case on Monday upper arch in 34 minutes from beginning to end, so from laying the flap, placing the implants, closing the flap and placing the prosthesis in 34 minutes. That's pretty powerful. And the reason why we were able to do that isn't because of me, it's not that I have any sort of God gift or anything like that. It's just that if you follow the method it becomes very, very predictable. And I have just the opposite, doc. I have people calling me after they've been placed at implants freehand for 10 years and they they literally are like holy shit, I can't believe that it was this easy. I'm sorry I cursed on your project.

Dr. Tyler Tolbert:

No, please, we do it all the time.

Dr. Robert Stanley :

They're like I can't believe it was this easy. I remember back I'm old enough to have done freehand back in the day. I remember placing implants and then going okay, take the radiograph. And I'd walk out in the hall and I'd lean up against the wall and I'd be like counting the seconds, wondering if I hit the adjacent tooth, and I'd walk around. I always made sure that the radiograph was up on the back screen, not in front of the patient. I needed to see that radiograph first and I would look and I would like, oh, oh, mrs smith, it looks great, you know.

Dr. Robert Stanley :

And then all the stress would go away and the minute you go to guide it and you know you can get a guide accuracy of about 200 microns, 200, 200 microns is your positional accuracy. With a guide, all that stress goes away. Now you do have to plan it right. It doesn't the brain part still needs. You still got to have the brain part. It's just the brain part has to go into the planning part, not during the execution. You still have to have a. You still have to be smart during the execution. But that's, that's my take on the, on the, on the guides.

Dr. Clark Damon:

Yeah, I think, I think you know I, we're able to optimize our implant position clinically and you know I can. I can tell you my implants I, I am typically able to get greater AP spread during surgery than I thought that I was able to uh when I was reviewing my uh x-ray and plan uh before. And so, uh, you know, I don't, you know we're, we're, we're very open, um, I mean, there's, there's a number of times, even when you follow key principles right, like perforating the nose with your posterior implant lift, lifting uh the nasal mucosa, being able to uh reach in there and have total control and total feel and have a, you know, a bear hug and a grip on this entire patient anatomy, uh to where you know, on on, on some cases, you've, you've chosen the correct implant, you just didn't have the correct patient and that patient, just, you know, systemically uh has a lot of challenges, especially with with their bone. You know postmenopausal females, uh, you know whether they, whether they have teeth or not. I mean, I look back at over the past year I have had I can think of three patients right now off the top of my head that had teeth.

Dr. Clark Damon:

We extracted, we did. You know just our standard, all on X procedure and you know, even placing the smallest drill and and compressing that bone, going to the floor of the nose, uh, going to cortices, using all of the principles, uh, that I teach, I I had, I had no torque on three implants. I've, I've had three patients that have wound up with with a quad, uh day of surgery that had teeth due to, uh, just just you know, uh, uh, their, their bone, and so uh, did they have stability?

Dr. Robert Stanley :

though they had zero torque, did they have stability?

Dr. Clark Damon:

Well, if they don't have any torque, I mean that's, we're not, we're.

Dr. Soren Paape:

I'm not.

Dr. Clark Damon:

I don't load, I don't know. I mean, you know if, if I don't get again.

Dr. Clark Damon:

I practice predictability and so if we can't get 35 Newton centimeters of torque with stability, I'm not going to load it, and so we are going to deviate. We're going to deviate every time and we're going to go to Zygos and because, because we are going to predictably load, and so deviation in, in, in, in, my perspective is hugely beneficial for that patient, um, and you know, hugely beneficial for the, for the case success. And you know, now they move along, they get one surgery, one procedure. Yeah, it was, it was bigger than what they intended, but because we can, because we can shift on the fly, we're able to treat that patient better and we're able to optimize that case's outcome by, by pivoting interesting, so let me dr stanley just I have a quick question off what you said, um, do you load?

Dr. Soren Paape:

are you saying that you load your cases? If they are, it doesn't matter the torque necessarily, as long as the implant is stable. Is that what you were referring to there?

Dr. Robert Stanley :

Yeah, that's what I was going to go into that right now, okay.

Dr. Soren Paape:

I'm curious yeah.

Dr. Robert Stanley :

The idea of a cutoff at 30, 32, or 35 newton centimeters for your insertion torque. It's an interesting concept, okay so. And then you put it together for full arches. A lot of times people talk about the cumulative torque value, right? So you hear, if I don't have 120 across the arch, I'm not loading. So let me just start off by saying this I have loaded every single upper and lower case I've ever done in my entire career. I've never had a case where and they're all guided and I've never had a case where I didn't load it.

Dr. Robert Stanley :

And that includes all the bone quality. And we're working on the same patients, guys, right? We're working on the same 55-year-old patient with poor quality, right, they're taking a minimum of three meds. Some of them are, you know, pushing eight meds, right? Those are the people we're working on. They're not healthy. The bone quality, bone volumes, it's not there, right?

Dr. Robert Stanley :

So you say, well, how is that possible? Well, it comes down to a couple of different things. Number one when you freehand and you are hitting two different types of bone, you're hitting spongy bone and you're hitting compact bone. When you're freehanding, you can't hold trajectory. No one can. I don't care if you're Arnold Schwarzenegger, you can't hold trajectory, okay, so you can try, but you can't.

Dr. Robert Stanley :

If you're placing a small implant and you go in and as you're doing your osteotomy, it's wiggling in. One time you're going this way and the next time you're going a little bit different, the osteotomy that you made is not the right size, and so you get an implant that has no stability, it's just floating. It's a, it's a spinner or it's floating, okay. So that's the first thing that you can have. When you do guided and you're in crappy bone, you're in the same crappy bone. The guide is going to constrain your drill and it's going to hold you on target for every single drill. So the small drill, the medium drill, the bigger drill, then the implant goes through the guide. So the implant is being constrained too. So if any of those things hit hard compact bone up against spongy bone they don't get knocked out of position. Okay, they stay on target. So that's the first thing you're going to get. You're going to get an increase in primary stability by using a guide, because you're going to actually stay on target through the entire osteotomy and drope and the implant placement.

Dr. Robert Stanley :

The second thing is that we've been kind of misled with the concept of torque. Okay, so most dentists have taught that torque equals stability and torque does not equal stability. And I'm going to prove it to you in the next 30 seconds and you're going to be shocked. Okay, here we go, ready. You're going into a patient on the lower anterior. They're 60 years old. They've been wearing a denture since they're 19.

Dr. Robert Stanley :

You know that lower anterior bone is going to be rock hard. There's no spongy bone, it's all D1 bone, really really hard bone. It's all compact. You drill your osteotomy right. You drill your entire osteotomy protocol and because it's D1, you're going to do something called tapping the bone. You guys remember the taps. They used to have taps in the kits in the old days. So you're going to get your tap and what your tap is going to do is it's going to cut a groove in that D1 bone. You're going to cut the helical spirals where the threads are going to go. So you go in and you tap it and then you take the tap out, you grab your implant and you put your implant in the hole. What would you think your implant torque would be in that case?

Dr. Tyler Tolbert:

Zero.

Dr. Robert Stanley :

Yeah, Maybe three Newton centimeters. What do you think your stability is? Your entire implant, 10.5 millimeters long surrounded by two millimeters of bone, compact bone all the way around it.

Dr. Tyler Tolbert:

Yeah, you had zero, so it's not going to move.

Dr. Robert Stanley :

Exactly and you've got 100 stability. You couldn't wiggle that thing out. If you tried, if you got on it with a, with an ash force effort, you tried to pull it out, you couldn't pull it out. The only way you're going to get that out is put a reverse torque on it and back it out along the path of the threads. So now you're now you're starting to think wait a minute, now maybe we've been misled with this concept of torque, because people are so fixated on torque that they're changing their protocol and they say, well, I'm not going to load this case or I'm going to pivot in real time and add extra implants in other locations because my torque was low. Now I've I'm going to tell you right now, I have loaded every single case and I don't.

Dr. Robert Stanley :

I record the torque for for the treatment notes, because it's because people still think it's the standard of care to record the torque right. So we record it. But I record 16 newton centimeters, 12 newton centimeters occasionally on implants around the horn. I don't care, as long as I can screw the multiunit on there without it moving and I can attach it to the rigid long-term provisional. That implant will integrate and you will have success.

Dr. Robert Stanley :

So it's a complete paradigm shift and that's why I keep saying cumulative torque value was a man-made construct. It was made by us. Where do you think 30 newton centimeters came from? Why 30? Isn't it coincidental that the Brandenburg implant, which was made out of a soft grade one, titanium, had a limit out of it at 30 newton centimeters because this the abutment screw stripped. So imagine you're an early implantologist, the guys that are actually now the old guys teaching at the universities, and they kept saying be careful about torque, be careful about torque, be careful about torque. And what they were really worried about is stripping the abutment in the implant. They weren't talking about the implant to bone, but over time it's very easy to see how people would mistake that and think we're talking about torque to bone.

Dr. Clark Damon:

So the fact that we're using 30 for that is arbitrary. Yeah, but a lot of your thoughts there, I think, apply to mandible but it doesn't apply to the maxilla. So for example Mollo's initial study, 245 patients mandible. They had 98% success and you know, obviously these were the older implant styles. When they went to the maxilla they had 30% failures. They did not have a stability or a torque requirement and so once they raised that to load it, then their success rates went to 97%. So yeah, I mean the maxilla is just different bone.

Dr. Tyler Tolbert:

So I'm curious, dr Stanley, about loading um, loading everything right. So even if you get less than, say, 20 newton centimeters of torque, um, is that to say that you just maybe like hand tighten a multi-unit onto?

Dr. Robert Stanley :

the implant. All of my multi-units are hand tightened. There's no, there's no wrench at the time of placement okay, and then are you using?

Dr. Tyler Tolbert:

so you use the tap analogy, which that's super interesting. The torque versus stability argument is very interesting to me. So are you actually tapping the bone when you use a guide or are you just using a traditional drill that's just going to make that hole Like? Is it tap prior to the implant going in to give you stability in those D4, D3, D4 situations?

Dr. Robert Stanley :

No, no, I haven't used the tap at a long time.

Dr. Robert Stanley :

The tap analogy is just to try to get you to think differently about the concept of torque, the concept of torque being torque is stability, which it's not, so you just have to keep that in your mind. Now, clearly, if you have higher torque, what you're doing is there's more compression of the bone from the implant going in. So the idea of undersizing an osteotomy meaning that you made the hole smaller means that when you put the thread in, it's going to compress the bone more. The bone is going to through Newton's laws, it's going to push back onto the threads. You're going to record that as torque, but really all it is is the compression of the surrounding bone. But really all it is is the compression of the surrounding bone.

Dr. Robert Stanley :

But the funny thing is is that you could go into a. You could go into a socket and engage compact bone at the apical aspect of the socket and engage just two threads and have 100 newton centimeters of torque and the rest of the. Say it's a 12 millimeter long implant. You could have 10 millimeters of that implant floating in the socket with nothing around it and the bottom two threads could be engaged in compact bone. And I've done this and you will measure 800 newton centimeters of torque. Okay now do you think that that has good stability? And the answer is no, because any sort of lobe, even putting the abutment screw on there, if you just wiggle it just a little bit it's going to evulse it right out of that hole because there's only two threads engaging. But if I go into D4, bone Any lateral movement.

Dr. Robert Stanley :

Pardon.

Dr. Clark Damon:

Yeah, any lateral movement in that scenario would.

Dr. Robert Stanley :

But imagine this I go into D4 bone sub-antral, and I've got 10 millimeters of D4 bone and I put a 10-millimeter implant in there and I get 15 centimeters of torque. And I put a 10 millimeter implant in there and I get 15 centimeters of torque. Do you think an off-axis load with my screwdriver, with my 050 driver, is going to evulse that implant? And the answer is no. But even though the bone is like styrofoam, even though the bone is very soft, the fact that you have all 10 threads engaging the bone is going to be more stable at 15 centimeters with 10 threads engaging than two threads giving you 100 newton centimeters of torque, do you see? So this is a this is a paradigm shift that is really important for people to understand because it changes the way you think about how you do implants. So even if I'm going into a healed site and it's d4 bone and I have low, I have low torque, which is what you would expect I don't care. I don't care because I have stability. It's not going to go anywhere. And remember what we said the prostheses that we tie to the top of this acts like bracing. It holds everything else together. So the common term is cross arch stabilization right, that's what people like to call it right. Cross arch stabilization term is cross arch stabilization right, that's what people like to call it right.

Dr. Robert Stanley :

Cross arch stabilization A prosthesis is not a prosthesis in engineering, it's a prosthesis in dentistry. In engineering, it's bracing. So if you put a post in the ground with cement, you would put some triangular two by fours around it, called bracing, to hold it while it sets up. Okay, In the mouth when we place the implants, we're going to brace the implants with the prostheses. We're going to hold all of those implants in place with the teeth. Dentistry. We call it the prostheses. Engineering, we call it bracing. But they're doing two different things, aren't they? So by tying it together, you get that cross arch stabilization and you're going to get great outcomes. You're going to have just wonderful outcomes. And I don't ever calculate cumulative torque value.

Dr. Clark Damon:

So I do agree, I don't calculate cumulative torque value and you know it doesn't apply in my hands because we're getting 360 plus cumulative torque value for all of our arches, of our arches. But you know, while your implant, sub-anchorly at 15 newtons may be quote-unquote stable, and while I do agree that we do have a bone splint with all of the abutments and everything glued together, just from a predictability sake, I do think that that would work on occasion, but it's just not predictable. And so, you know, in my offices I can't. You know, we're doing 25, at least for me, I'm doing 25 to 30 arches a month plus my associate. I don't have time to basically have failures, and so that's where I opt for a more predictable approach.

Dr. Robert Stanley :

I'm going to have to reiterate something I have never had a full arch case not loaded, and I've only had two cases where I've had catastrophic failures, where they were both on smokers in my career. So it's either I'm lying or I'm gifted by God, or the third option is the method works. So I would hope you guys would take the first two as kind of funny, but the last one is the truth, and that is if you follow the method, you get great outcomes. I tell people, listen, if you turn the Toll House cookie bag over and you follow the instructions in the back, you're going to get good cookies right. And so if you're not following the instructions, you don't get good cookies. And so, with respect to implants, if you follow the method, you'll get great outcomes. I don't have time for me. I despise failures. I'm a winner, and when I have a failure I lament it for days. I mean, it drives me crazy and drives my wife even more crazy.

Dr. Tyler Tolbert:

So so if I were to, if I were to paint a portrait of the two opinions here that are opposing, that claim to be reaching the exact same result, right? So, on one hand, we have less implants, high cumulative torque value even though, dr Damien, I know that you're not necessarily saying that's what it's all about but less implants, high torque value is creating stability with rigid fixation. Alternatively, dr Stanley, fairly irrespective of the torque, you have more implants that are rigidly fixated and you're getting the same success rate. Is that idea that, because you have more implants are being fixated to each other rigidly by the, by the material itself, be it the nanoceramic or the zirconia? That's why the torque doesn't matter and that's why you're able to sort of get away um with doing the, the short implants being placed actually because of that fixation, regardless of the individual torque on the implants. I just want to make sure that I'm characterizing your argument correctly.

Dr. Robert Stanley :

So, first of all, I don't think that we have much of a difference in the number of implants, because I believe that the vast proponents of your cases are going to have six implants, and so am I.

Dr. Tyler Tolbert:

The number of implants are about the same Per square area, right? Okay, so the AP spread, so there's a bigger AP spread.

Dr. Robert Stanley :

The advantage to the AP spread is to have a terminal abutment and reduce your cantilevers, which is a good mechanical principle, right? It's one that we drive to. If you do use a cantilever, just keep it short, right? And then, if you do have a cantilever, your beam has to be thick enough, it has to be made out of a strong material and the implants that you're using have to be strong. So there's a lot of implants out there that are grade four implants. They're 36% weaker than titanium alloy. So, if you see, you're following the recipe now, right? So I just gave you the Toll House recipe here for success, if right. So I just gave you the, the toll house recipe here for success. If you have a cantilever, it should be short. If you have a cantilever, your prosthesis should be made out of a strong material zirconia. It should be tall 13 or more millimeters in height, so FP3, and then your implant can't be, it can't be a weak implant. You have to use a strong implant. And then, and then the last thing is your implants have to be in the right location, so they can't be just haphazardly placed. They have to be in the right location to support the loads. Okay.

Dr. Robert Stanley :

If you put all that together, you have a recipe for success, irrespective of cumulative torque value, irrespective of individual torque value. And I believe the reason that they integrate is because they're not moving. So it's not about your initial torque, that gives you stability, that gives you a win. It's about lack of movement, right? If we have movement during the healing, if the implant moves, it won't integrate. You'll get fibrous ingrowth, right? We all agree on that. I don't think there's anybody that would argue go ahead and wiggle it and see what happens. It just doesn't heal.

Dr. Robert Stanley :

But when you have implants and they're in bone and they have stability and you tie them together, they don't move. There's no movement. We don't let them chew on these teeth right away, okay. So just to be clear, my protocol is they're on a liquid diet for two months. Okay, and that's rather extreme. People will say two months, that seems like a long time. Can't you go shorter?

Dr. Robert Stanley :

Guys, if you've been practicing for a while, you know that when you ask someone not to chew on teeth for two months, you'd be lucky if you get a month right. You know how that. You know we're going for two months of liquid diet. But that's the goal and if I can get to two months and if and I've had three, three or four patients that actually did it and we know how we know when they come back at two months they've lost 15 pounds. We don't have to ask them 15 pounds, we don't have to ask them, they just go. God doc, I look great, I lost 15 pounds. Thanks a lot for the benefit. You know, but that's how you know that. But most people, most people, are probably eating on it.

Dr. Robert Stanley :

But the fact is is you're driving for that initial stability being no movement. No movement is the key. That's that's key. So it's not torque, it's not compression of the bone. That's that necessary. If you had the idea that you were going to let them go out and chew on those teeth right away, you would have problems right, because now you're going to need to have higher stability based on engaging more compact bone rather than just bone in general. So then you're going to go to bicortical stabilization and those kinds of things.

Dr. Soren Paape:

So for your guided cases. Just I'm curious, are you doing stackable guides typically so yeah, or are you doing yeah?

Dr. Robert Stanley :

So I worked really closely with NDX back in the day, with the initial guys that created NDX and created those patents, so it was really instrumental in giving them feedback which helped to improve the stackable solutions over the years. Then some of the guys from NDX spun off and started their own businesses and what they did is they made an approach that is not stackable. So S3, simple Smile Solutions, is one of the companies I work with closely now. It's not stackable, it's fully guided but it's not stackable. And one of the advantages of that with the new system is that they looked at, they invented the original system. So then they said, okay, what can we do better? They can take a guided case and they can actually provide it to you as a clinician with like three or four parts total, like you could do the whole case with three, three printed parts. It's amazing how they have really streamlined it. So stackable solutions work great.

Dr. Robert Stanley :

There's a lot of them out there. There's a lot of copycats now I don't know how they're getting around the patents, because there are patents out there, but they're getting around it. Um, I think that probably because there's so many people doing it, it's hard to just go after them all but stackable solutions work really well, but a lot of the copycats are starting off with stackable solutions that are about seven years behind the technology. In other words, the original stackable solutions are being copied versus the evolution of the stackable solutions that have occurred over the last 10 years, and the evolutions are subtle. Right, there are very little subtle details in terms of how you actually implement a stackable solution to improve the workflow so you can do it in an hour, right, and the new guys.

Dr. Robert Stanley :

You've got to be careful what I'm just saying to the people that are listening. If you're going to use a stackable solution, I would really encourage you to go and look at somebody who's been doing it for a while and not to say that the new guys can't do it, but I would encourage you to look at the way the guys have been doing it for a while. They're doing it because they have had the feedback and they've improved their systems. So that's my suggestion on that. Did you have a question about the stackables?

Dr. Soren Paape:

that's my suggestion on that. Did you have a question about the stackables? Yeah, and I it was more of like a you know, predictability thing too. Um, just a couple points that, um, I think are important to address. And I'm curious, like what, how you manage it in your clinic?

Dr. Soren Paape:

Um, one of those things is, if you're doing, uh, I guess I guess the the better point is I see people that have issues with guides, right, when we have a situation where maybe they plan the case as a stackable case and then they go in and they, you know, let's say, the patient has like 10 to 12 teeth and those teeth are severely decayed but really good root structure, and they go in and they're taking the teeth out and all of a sudden they have a fracture, buckled plate on one of the, on one of the, uh, the roots, um, and then, and that's a location that your implant is planned and guided, and they, they have this stackable case in their office that they paid X amount of dollars for and that's a key position for one of those implants and, um, you know, it probably wasn't, you know, could have been the provider's fault, right, but maybe it was just a really difficult tooth to come out and that buckle plate fractured off and it was in one of those key positions of their implant.

Dr. Soren Paape:

And it doesn't matter what the torque value is or the stability is of that implant, but it's in a very critical position that now they can't use anymore. It's no longer usable, what you know. What is your solution in that situation? How do you manage that for a new guide? Do you go replan the case, print another guide in your office? What does it look like in that situation? Do you then go freehand in that situation? And if you do go freehand in that situation, if the guide is stackable, you have the teeth prefabricated. I'm just curious how you'd manage that in that particular situation, and I feel like that's a pretty common thing that might happen.

Dr. Robert Stanley :

Yeah, that that is so. So first of all, I'll say in my course I offer a one hour lecture on how to take out teeth without that happening. Okay, so, so used to drive me crazy. You know, in in in school, the oral surgeons would come in and said the best, the best, uh, the best way to prevent, you know, the best solution to these complications is prevention. Right, they used to say that all the time. You know, case selection and prevention is so important. So, first, learning how to take out teeth atraumatically so you'll never have that happen, if you take my class or you watch my video online on my YouTube channel, you will never break a buccal bone ever again in the aesthetic zone, ever. It just won't happen. Okay, so it's just that simple. People are shocked. I got compliments this week and I was at Affordable's annual meeting and I had people coming up that recognized me and they were thanking me for the extraction video on how to take out teeth atraumatically.

Dr. Clark Damon:

So if you haven't watched that, check it out I on how to take out teeth atraumatically. So if you haven't watched that, check it out.

Dr. Robert Stanley :

I think you'll get a kick out of it, or come to the class and you'll get even more details. But in the aesthetic zone you will never fracture another buckle plate ever In the posterior. If you're taking out a molar and you're using some 88s and you've got an old person and it's brittle, it's possible that you could fracture some of that. Okay. So you do have this happen. Okay, for the sake of the argument, because let's say, you just did all right. Well, we're doing an FP3. So typically with FP3, we're going to do longevity leveling. So longevity leveling is after you take out the teeth. You're going to take off, the bone is going to be jagged, right. And we want a nice level bone. And the reason we want a nice level bone is that when we build the prosthesis, it's nice and smooth, it's not concave and the patient can keep it clean. And you've got longevity right Because they can keep it clean real easy. So when we level that bone, what do we do with the bone? Well, we don't throw it away. We have autogenous bone, which is the gold standard for grafting, right. So what am I going to do with it? I'm going to put it in my bone mill, I'm going to grind it up and I'm going to have it ready.

Dr. Robert Stanley :

So at the time I'm done with the implant placement. I have a four wall defect, so I have the apical, the lingual, the mesial and the distal are all intact, but the buckle's missing. I got stability on the implant so I'm going to graft around it. I'm going to graft with what? Autogenous bone? You want to talk about having an amazing outcome.

Dr. Robert Stanley :

Graft with autogenous bone? There's not. You can't buy bottle bone anywhere. That's as good as the human bone. It has all the growth factors, osseoinductive, osseoconductive it's all in there. You heard Craig Misch talks about it all the time. It's the gold standard for grafting. So I'm going to graft, I'm going to put a little, I'm going to put a collagenF over that and we get primary closure and I'm going to close it up and I'm going to tie it with the rest of the teeth, with the rest of the implant to the prosthesis and I'm going to proceed. It's a simple solution. Now, how do I know I'm going to get, even without the buckle bone, with a buckle bone blowout? Did I need that for stability? And the answer is no. We rarely engage the buckle bone with an implant.

Dr. Soren Paape:

Really, yeah, I wasn't saying you need it for stability.

Dr. Robert Stanley :

I was mainly concerned with Just so that anyone was getting confused. We don't need that buckle bone. We're not trying to engage that buckle bone for stability and that's how we would manage it.

Dr. Soren Paape:

On the subject of, and that makes sense, I do the same thing Every single case that I do. When I'm removing my bone. I typically use a ronger and then use a bone mill, grind it up and then use that for my graft and all my sockets, and I think it's a really great outcome and I was just curious how you manage that. The second question I have is in an office right, let's say like an office, like Clark's office, where, and maybe your office too I'm not sure how many arches you're doing in your office, but some of these clinics that are doing 20 plus arches a month do you think it's predictable for those offices to be paying for guides for all their cases and then also managing the production, ensuring that whoever you're hiring to make those guides is doing it well and going through all these cases with them? Is that like a huge time constraint for you? Have you found it to be pretty efficient at this point? Where are you at?

Dr. Robert Stanley :

Yeah, so all the data acquisition is done by my team members. So I have a patient who agrees that they're interested in doing full arch or full mouth. All the data acquisition is done by my team members. Then we sit down. Once the data is sent to the planning company, the planning company plans it. Then we do a go-to meeting and that go-to meeting takes me about five minutes now and most of that is just chatting with my friends on the other side. But we're going to step through each implant and we're going to verify position and it meets all of our guidelines for placement right, and so then we're done. Okay, and then the guide shows up in the mail a couple of weeks later, whatever, depending on the timeframe, and we schedule the patient for surgery. We go through the normal medical clearance and we get them in. We do surgery and we do. All of our cases are sedated and we do it.

Dr. Robert Stanley :

So I'm in and out for on average I'm doing an arch in an hour, on average a little, sometimes a little bit more, sometimes a little bit less, but on average is about one hour per arch. So imagine you're doing a high volume clinic, so you start at eight. At 10 o'clock you're done with the first case from 10 to 12, you take a donut break at 12, you start your second case at two, you're done. You just did. If it's $70,000, $60,000, $70,000 for full mouth, you just did $120,000, $140,000 of production in four hours. If I'm a DSO or I'm a high-volume practice, you got my attention. That's a business model that I can spend a few hundred dollars on making a piece of plastic to have this kind of production.

Dr. Robert Stanley :

Now here's where people don't understand. I saw a patient today who drove down from Virginia, so that's about a three-hour drive from where I live. They drove down to see me because they had an all-on six-placed screw retain that they never were comfortable with and the doctor took the prostheses out, went to a locator solution they weren't comfortable with that took out a couple of the implants and he came to me with three implants and a denture. He said can you help me? Okay, so this is what we see in our practice all the time with freehand, and it's not that just to be clear. It's not that you can't do freehand and be successful. You can. But if you really really want to be predictable on each case, each case, each and every case, and putting it into the hands of, say, somebody who's not quite as gifted, right. So some people are gifted in dentistry. They have the hands of Michelangelo, right, and others aren't. So implants are a great place to live.

Dr. Robert Stanley :

If you're doing guided, if you don't have hands, if you have a hard time doing crown preps, then implants are where you should be, because you don't have to have that kind of dexterity. My hand doesn't get in the way of the video and so you go. Well, isn't that dangerous? No, yeah, I'm in a guide. The guide's constrained in the position of the of the drill and the implant, so there's no risk to the patient. But I do that so you guys can see that in the clinical videos how to do it. So if I'm running a business and you tell me not only can you do it faster, but I'm going to have less downstream complications, less bad Google reviews.

Dr. Robert Stanley :

I never got my teeth, this guy's saying. I never got my teeth to work, I paid for full arch and now I'm down to a locator denture. The guy was even talking about taking out their three remaining implants and doing a denture. He's going the wrong way. Usually people start with dentures and work their way into locators and then to full mouth to a screw retain. So the poor guy was going the wrong way. So I can build a business model. That's just the opposite of what most people tell you that if you really want to be profitable in full arch, then you want to do fully guided and you can bring these services in house. If you're big enough and you're doing this, you just bring that design service in house and now you're really driving your costs down and you can get a printer. You can even have a design service done in Egypt and have the guide printed in your office the next morning I was going to ask you that, pardon, do you do?

Dr. Soren Paape:

are any of your guides? I was going to ask you about that. Next, are any of your guides printed? Are you? Typically, it sounds like you would get yours shipped in, but have you tried? It sounds like you have printers in your office. Have you tried printing them in office? Oh, yeah, have printers in your office. Have you tried?

Dr. Robert Stanley :

printing them in office. Does that work well for you? Yeah, most of our full mouth, no, but we have done that before. But because full mouth isn't normally I need full mouth tomorrow, right? There's never really when they come to you it's not like, oh, I've got to do full mouth tomorrow, right? There can be time pressure, like I'd like to be done by May, you know, in a couple of months for my family reunion. That can happen. But typically you don't have that time pressure that you have with a onesie-twosie implant, right. So the onesie-twosie implant, somebody has an acute affection and you want to do it immediate, or something like that. Then you want to print it in the office right away. That makes a lot of sense. But for full arch, typically you can wait. You can wait. But if you really are pressed for time and sometimes that happens you just talk to the design service company and you have them send you the print job straight to your printer and print in your office.

Dr. Robert Stanley :

And that's really another subject you guys can talk about in the future on your podcast is the globalization of dentistry. And you can have listen, egypt is sleeping right now. Right, and in a couple of hours, when we're off this podcast. They're going to be waking up so they could be planning your case while you're sleeping. If you wake up, the case is planned, so talk about efficiencies.

Dr. Robert Stanley :

You know like and it doesn't have to be Egypt, I'm just saying somewhere else on the planet you can have a design service and so what we're going to see, in my opinion, is that you're going to start to see digital laboratories, a consolidation of the digital technology into some big laboratories that do the planning for everybody, and they're going to be super efficient. They're going to know exactly where the implants need to go. Each doctor could have their own set of preferences. This is exactly where I'd like all of my implants to go. If they're a pterygoid, this is where it needs to go for optimal solution, and they do it digitally, and then you just get on the computer and you verify it, you give it a thumbs up or thumbs down and you're done.

Dr. Tyler Tolbert:

Dr Stanley, one point that I did want to kind of clarify.

Dr. Soren Paape:

I appreciate it. Thank you, by the way. I appreciate the insights. Yeah, go ahead, Todd.

Dr. Tyler Tolbert:

Yeah, yeah, no problem. A point that I did want to clarify in terms of the stability of the implants, even in softer bone right and I'm trying not to conflate this with torque, though it's hard, no, it is hard, isn't it? It is, it is. So is the idea that, because you're placing an implant along a constrained path, that the implant is inherently more stable, irrespective of torque, because it's constrained? You talk about and you have a video on this too. You know, when you're trying to place it freehand, you're going through heterogeneous bone right. There's areas of D2, d3, d4. Your drill is glancing around a little bit and you're actually widening the osteotomy a little bit in different places. Is your idea that, because it's guided and it's constrained, the implant is being tapped in and you have better bone implant contact, that that is giving you some stability as well? Is that part of the argument too? That's correct.

Dr. Robert Stanley :

That's absolutely correct. So what happens is that if you're freehanding it, you're feeling the bone. So freehand dentists will say I'd like to feel the bone, I'd like to feel that tactile feel. And that makes sense because you can feel it right, you can feel I'm hitting hard bone here. Oh, I know what that is. You're visualizing the anatomy in your head as you're drilling. You go oh, I know what I'm, I know what I'm touching up, that's what. So they're feeling it.

Dr. Robert Stanley :

The problem is is that as that drill goes in, if it comes out a little, if it goes in this way and it comes out a little bit like this, it now made a hole, that's it's wider than the pen, right, it's wider than your drill. So now you go in, your osteotomy hole is bigger than you wanted it to be. It's not. It's not as tight as you want. So remember, the idea behind undersizing an osteotomy is to make it smaller so that you have more compression of the bones, so you have better stability, okay, well, if you're going in there freehand and every time you go in you go in a slightly different angle, the final hole you get is not going to be designed.

Dr. Robert Stanley :

What in engineering it's called the pitch diameter. Okay, the engineers have designed that, the final, the final drill to match your implant specifically. And if you, if you waller that hole out that's what we say in the South, here we say waller it out If you waller out that hole, the hole is going to be bigger. So you've done the opposite of osteodensification right. You've made the implant more loose in the hole and that's more inclined to give you something that has zero stability, basically a spinner or zero stability.

Dr. Tyler Tolbert:

Right. So the antithesis of that is, of course and, Damon, I'll let you finish there, Sorry the antithesis of that idea is, you know, the idea that we can anchor extra long implants and only just a few millimeters above right and that's really the whole concept of a remote anchorage implant is we're able to still get stability just off of just a few millimeters of density. But sorry, Dr Damon, I didn't mean to interject.

Dr. Clark Damon:

Well, I was going to say that you know Waller, waller. I don't even know how you say that, waller.

Dr. Robert Stanley :

Waller.

Dr. Tyler Tolbert:

It's not spelled, it's only said.

Dr. Robert Stanley :

There's no spelling for it.

Dr. Clark Damon:

You know that is obviously not the goal of freehand, right? So saying that that happens in freehand is like well, that that could happen into a more inexperienced provider, but not that doesn't happen, that's. That's not a applicable statement to all free hands so I will argue.

Dr. Robert Stanley :

I will argue the contrary to that in the following way compact bone is 10 times stiffer than spongy bone. So the modulus of elasticity of compact bone is 10 times stiffer than spongy bone. That's why we call it spongy bone, right? I don't like to use cortical bone or trabecular bone because it modifies the water. We're going to call it spongy bone because it's soft like sponge. Okay, so now it's almost like this little foam foam on my microphone here. It's spongy and compact bone is ten times harder. So the problem is is that whenever you hit compact bone anywhere in the mouth, that that drill is going to kick off that compact bone and slide into that, into that soft spongy bone, every single time, with or without experience. Now, with experience, you can learn to try to compensate for that, right, you learn with time. I'm feeling it. So I have to push this way or that way to try to get my implant on the right location. But it is a mechanical constraint, not a clinician, it's not a hand skill. You see, it's a physics issue. You are going to.

Dr. Robert Stanley :

If I asked you to place an implant and I wanted you to drill, I wanted you to drill right on the edge of the bone. So the bone is compact and on the other side is air. Well, pretty much anybody can't do that, right? But I can do that with a guide. Do you see? One side's air. So as you try to drill down, this side over here is bone and this side over here is air. As I try to drill down right halfway on bone and halfway on air, it's going to kick out into the air every time, right? Unless I have a guide on the side of the hard bone. So that's the difference. And so the difference is is that instead of using air, so I use air as an analogy, so people can kind of understand. But if one side is spongy and it's 10 times weaker than the other side, it does the same thing it gets knocked off that hard bone.

Dr. Robert Stanley :

Now you say, well, where's the hard bone? Well, the obvious location for hard bone is where we all know it to be, and that's on your cortical plates, right? Your buccal plate, your lingual plate. We all know that. But vast preponderance of these people are not coming at us with healthy teeth, right? So a lot of times you have focal sclerosis, don't you? You have idiopathic sclerosis apical to your extraction socket. So I call those little landmines. So you're going in, you're thinking everything's great, you get towards the bottom and all of a sudden you hit some of these hard bones, the hard, dense, bony islands, and at the very bottom there your implant gets out of position a little bit and for onesies, twosies, the free-handed dentists go oh, that's not exactly where I wanted it, but I guess it's good enough. And then they leave it. And then what happens? It integrates, because the first rule of implantology is if the implant's placed in the wrong position, it integrates we all know that.

Dr. Robert Stanley :

So then what happens is they put a Snoopy on there and then the Snoopy is on there for about two and a half years and then the screw, the screw loosens, and when the screw loosens, the abutment loosens and the abutment breaks the implant and they go. What happened? Well, it's two and a half years and the most most dentists say what, mrs Smith, what did you eat last night? Cause, clearly it the blame on the patient. And this was a problem that started the day the implant was placed. And we see it all the time, and we have the benefit of the time because these failures they fail through a mechanical mechanism called cyclic fatigue, right, fatigue failure. Fatigue failure is if I have a coat hanger and I bend that coat hanger back and forth really fast, it gets hot and then the coat hanger breaks. So if I have an implant and I bend it back and forth enough times, it will break, okay. And so in our case, that typically takes about two and a half to three years before it starts to break, Depending on the implant you use.

Dr. Robert Stanley :

If you use a weaker implant, it's going to break readily. So the time difference is our saving grace, because if these things broke within the first week, we would all be changing our methods. They're not breaking in the first week. So we have this time between the placement and the failure and we have what we call plausible deniability. We go Mrs Smith, what did you have for dinner, like what she had for dinner the night before, caused the failure. Right, that's not what caused the failure. It all goes back to the implant was placed in the wrong position and it was a weak implant.

Dr. Clark Damon:

Well, I mean, I, I, I think that guides have a place for single implants. Uh, just not, not in, not in full arch, and so um, which brings up a really good point. You know, as, as you were talking, I haven't done a single implant in probably three years. All I've been doing is is, is, is is fixed arches, which is really, really nice. You know, we, we have ways to navigate, you know, kind of around those. You know, for me, I really lock my wrist and you know, there isn't, there is no wrist bending. But you know, I, I don't necessarily think that complications are due to lack of guide versus freehand. I just think that complications are due to a lack of ability to execute, and so that's, that's right.

Dr. Robert Stanley :

I wouldn. I wouldn't disagree with you at all. I would say 100%. You're right. It's all about the execution. I have an analogy I say everybody goes to the Super Bowl or the World Cup with the plan to win. Both teams plan to go to win right and we all know if we watch sports at all we all know that typically the team that executes their game plan wins the game right. It's usually the team that doesn't turn the ball over, that executes their game plan appropriately, that ends up winning, and they don't have the mistakes. I look at the guide as simply a tool to help me execute my game plan. That's how I look at it.

Dr. Tyler Tolbert:

Fair enough. Fair enough, would you say. Dr Stanley, you did kind of talk about you know the role of DSOs and the potential, you know upsides, of using a guided workflow. It seemed that you were inferring though you didn't say explicitly that a less experienced clinician you know it can at least take teeth out atraumatically would have more success using this guided workflow because it's not as technique sensitive. Is that something that you would agree with?

Dr. Robert Stanley :

A hundred percent. The planning still has to be done properly because, remember, if you plan wrong, the guide will give you the wrong answer. The guide doesn't fix wrong planning, so you do have to be educated on the planning. So let's say the planning is done properly. We'll make that an assumption. The planning was done properly, then I I routinely have people do over the shoulder for their first implant cases, for their first implant cases, full arch cases over the shoulder, and it's world-class outcomes. And it's the first case I ever did and they and they have no, no, no experience whatsoever because it's just a tool.

Dr. Robert Stanley :

I have another analogy here's. Here's an analogy if you do any woodworking and you and you have to make repetitive cuts in the in the garage, you make a jig, right. If you, if you do any, if you do, uh, any clothing, you do any fabric work like sewing or something, you make a pattern and then from the pattern you make the right. So the guide in dentistry is just like those two analogies. The guide just simply helps you get the implant on the right location. That's why I don't get real fanatical about it. It's just the tool. And if you can accomplish it without the tool, great.

Dr. Robert Stanley :

I just can't do it repetitively. I could do it occasionally, I just can't do it on every case. Then you ask the question repetitively I could do it occasionally, I just can't do it on every case. Then you ask the question which patient deserves your less than best performance? Is it going to be your mom? Maybe your sister, your daughter? Who in your practice are you going to do dentistry on and say I just wasn't on my game that day? So I would prefer to say my game is always A plus, and it's always A plus because I use these guides and the guides get me in the position that we planned to go, that's all.

Dr. Tyler Tolbert:

I understand, yeah Well.

Dr. Clark Damon:

Hey, uh, I got a question. Um, you know, you know there's been a lot of talk. Uh, you know, stanley, I don't know how big into the full arch game your practice is, but you know what are you seeing on, you know the East Coast, what are you seeing kind of in your market? And I'll just kind of tell you what I am seeing.

Dr. Clark Damon:

What has been very interesting for me is every year I've been able to charge more for my arches and uh, you know, and every year I'm doing more and more arches, uh, even even being in Dallas, and as, as, as as you're well aware, you know, dallas led the nation in fixed arches from probably about 2012 to uh, uh, 2018, 2019. And then it went elsewhere into Chicago and DC and, uh, vegas, um, but so, so, so, even in competition, I've been able to ramp up. I hear and I see other full arch, uh, heavy practices that are really struggling, um, and you know, I don't know, are you, do you have any thoughts on that? Are you seeing something similar? What? What are your thoughts in the market?

Dr. Robert Stanley :

So my my practice, I practice with my wife, we and we have been a fee for service practice since the early nineties and so we we still are fee for service. So our fees are set based on market value. And I do a lot of work with the DSOs and I do a lot of work with recoveries of people that have had full mouth attempted. So I see them come to me, so we have somewhat of a pulse on the industry. What I see is I see that there are people that are trying to acquire volume by reducing price and in doing so, they don't have the margins. And since they don't have the margins, they have to figure out a way to make it work. And the way that they do that is they cut out tools, right, like a guide. Like you're going to cut the guide out and they're going to cut. They're not going to do six implants, they're going to do four implants, right, they're going to. They're going to cut, cut, cut. They're going to. They're going to use a cheaper implant, and I don't mean an inexpensive implant, I mean a cheap implant, one that's made poorly, because that's where they're going to. They're going to save their money. You put all those things together and they can charge less, but they have a lot of complications and failures in the industry.

Dr. Robert Stanley :

And so I see, in my, in my area, I see a lot of problems coming to me from these big boxes. You know the big box companies that do lots of full arches and stuff. I get a lot of them coming to me after it goes to Cass I got this, got this doc, I got this done. Can you, can you help me?

Dr. Robert Stanley :

And it's after the fact and you guys know how hard it is because you really want to help these people and you go oh my gosh, you know that the implants they integrated because they're in the wrong spot or they're not deep enough for and you're trying to help them and they, they basically have an FP one with a high smile line and the transition showing and you're going yeah, guys, I mean, how did how did this even? How did this even happen from the beginning? You know, out the gate. It's. It's frustrating for those of us who are that really care about the patients and we're really trying to make a difference and you want to help them when they come and the only way to help them is kind of have to start the whole process over again Many times. It's really frustrating.